Aesthetic Dermatology

LAS VEGAS — When patients ask Dr. Ranella Hirsch what topical cosmeceuticals to apply regularly to their skin, she responds with the mantra "protect and repair."

"You protect in the morning," she said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "Your first-line agent should emphasize sun protection, but you can combine antioxidants with that to help prevent redness and other sun damage. At night, you want to repair with a retinoid or a peptide. Ideally, I like to have patients use a combination of products with complementary benefits. There is no one product that's going to do it all."

Dr. Hirsch, a dermatologist who practices in Cambridge, Mass., noted that sales of cosmeceuticals were expected to reach $7.2 billion in 2008, up from $6.4 billion in 2004.

"Baby boomers are being seduced by marketing and antiaging claims of these products," she said. "The question is: Can these promises be fulfilled? Cosmeceuticals are not subject to the [Food and Drug Administration's] rigorous approval process. What kind of advice can we give to patients about how these products work and what they can really deliver?"

She discussed the benefits of the following cosmeceutical ingredients:

▸ Retinol (vitamin A). Found in many skin care creams, retinol is a relative of prescription tretinoin. "It's less irritating than tretinoin," Dr. Hirsch said. "It can increase epidermal water content and epidermal hyperplasia, but mainly it enhances collagen synthesis. That's one of the main ways it decreases the appearance of fine lines. It can also interfere with melanogenesis, which helps lighten sunspots."

▸ Niacinamide (vitamin B₃). This hydration repair agent increases ceramides and free fatty acids in the epidermis, and improves the lipid barrier. In turn, it decreases transepidermal water loss. "We recognize that preventing transepidermal water loss is important, not just for the health of the skin but also for photodamaged skin," she said. "If you can restore that barrier and prevent water loss, the skin will feel smoother and plumper."

▸ Coenzyme Q10 (ubiquinone). This fat-soluble antioxidant downregulates matrix metalloproteinases (MMPs). By inhibiting them, "you can help decrease the collagen breakdown in the skin," explained Dr. Hirsch, who is the immediate past president of the ASCDAS. "They are coenzymes for steps in the production of cellular energy, and they inhibit lipid peroxidation of plasma membranes and prevent oxidative stress."

▸ Idebenone. This substance is a potent synthetic derivative analogue of coenzyme Q10. "In initial studies, it was found to be a very powerful antioxidant, also downregulating MMP expression," improving roughness and dryness, and hydrating the skin, she said.

▸ Polyphenolic flavonoids. Derived from plants, these substances are antioxidant, anti-inflammatory, photoprotective, and anticarcinogenic. They are contained in wine, tea, coffee, and soy.

▸ Green tea. This ingredient contains the polyphenols epicatechin-3-gallate and epigallocatechin-3-gallate (EGCG). Studies have demonstrated that pretreatment of human skin with EGCG mitigates UVB-induced erythema.

▸ Coffeeberry. Derived from unripe coffee berries, this extract contains the polyphenolic antioxidants chlorogenic acid, quinic acid, and ferulic acid. In vitro, it has been found to upregulate collagen and connective tissue synthesis and downregulate collagen breakdown, Dr. Hirsch said.

▸ Peptides. Matrixyl, a procollagen pentapeptide fragment owned and licensed by Sederma SA, reportedly stimulates production of collagen I and II and fibronectin by fibroblasts.

Another product, acetyl hexapeptide-3 (Lipotec SA's Argireline), claims to mimic botulinum toxin-like effects in vitro. Overall, she was skeptical about topical products with injectablelike claims. "Better than Botox?" she asked. "No!"

Dr. Hirsch disclosed that she is the senior medical adviser for Vichy Laboratories, a division of L'Oreal USA.

LAS VEGAS — When patients ask Dr. Ranella Hirsch what topical cosmeceuticals to apply regularly to their skin, she responds with the mantra "protect and repair."

"You protect in the morning," she said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "Your first-line agent should emphasize sun protection, but you can combine antioxidants with that to help prevent redness and other sun damage. At night, you want to repair with a retinoid or a peptide. Ideally, I like to have patients use a combination of products with complementary benefits. There is no one product that's going to do it all."

Dr. Hirsch, a dermatologist who practices in Cambridge, Mass., noted that sales of cosmeceuticals were expected to reach $7.2 billion in 2008, up from $6.4 billion in 2004.

"Baby boomers are being seduced by marketing and antiaging claims of these products," she said. "The question is: Can these promises be fulfilled? Cosmeceuticals are not subject to the [Food and Drug Administration's] rigorous approval process. What kind of advice can we give to patients about how these products work and what they can really deliver?"

She discussed the benefits of the following cosmeceutical ingredients:

▸ Retinol (vitamin A). Found in many skin care creams, retinol is a relative of prescription tretinoin. "It's less irritating than tretinoin," Dr. Hirsch said. "It can increase epidermal water content and epidermal hyperplasia, but mainly it enhances collagen synthesis. That's one of the main ways it decreases the appearance of fine lines. It can also interfere with melanogenesis, which helps lighten sunspots."

▸ Niacinamide (vitamin B₃). This hydration repair agent increases ceramides and free fatty acids in the epidermis, and improves the lipid barrier. In turn, it decreases transepidermal water loss. "We recognize that preventing transepidermal water loss is important, not just for the health of the skin but also for photodamaged skin," she said. "If you can restore that barrier and prevent water loss, the skin will feel smoother and plumper."

▸ Coenzyme Q10 (ubiquinone). This fat-soluble antioxidant downregulates matrix metalloproteinases (MMPs). By inhibiting them, "you can help decrease the collagen breakdown in the skin," explained Dr. Hirsch, who is the immediate past president of the ASCDAS. "They are coenzymes for steps in the production of cellular energy, and they inhibit lipid peroxidation of plasma membranes and prevent oxidative stress."

▸ Idebenone. This substance is a potent synthetic derivative analogue of coenzyme Q10. "In initial studies, it was found to be a very powerful antioxidant, also downregulating MMP expression," improving roughness and dryness, and hydrating the skin, she said.

▸ Polyphenolic flavonoids. Derived from plants, these substances are antioxidant, anti-inflammatory, photoprotective, and anticarcinogenic. They are contained in wine, tea, coffee, and soy.

▸ Green tea. This ingredient contains the polyphenols epicatechin-3-gallate and epigallocatechin-3-gallate (EGCG). Studies have demonstrated that pretreatment of human skin with EGCG mitigates UVB-induced erythema.

▸ Coffeeberry. Derived from unripe coffee berries, this extract contains the polyphenolic antioxidants chlorogenic acid, quinic acid, and ferulic acid. In vitro, it has been found to upregulate collagen and connective tissue synthesis and downregulate collagen breakdown, Dr. Hirsch said.

▸ Peptides. Matrixyl, a procollagen pentapeptide fragment owned and licensed by Sederma SA, reportedly stimulates production of collagen I and II and fibronectin by fibroblasts.

Another product, acetyl hexapeptide-3 (Lipotec SA's Argireline), claims to mimic botulinum toxin-like effects in vitro. Overall, she was skeptical about topical products with injectablelike claims. "Better than Botox?" she asked. "No!"

Dr. Hirsch disclosed that she is the senior medical adviser for Vichy Laboratories, a division of L'Oreal USA.

LAS VEGAS — When patients ask Dr. Ranella Hirsch what topical cosmeceuticals to apply regularly to their skin, she responds with the mantra "protect and repair."

"You protect in the morning," she said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "Your first-line agent should emphasize sun protection, but you can combine antioxidants with that to help prevent redness and other sun damage. At night, you want to repair with a retinoid or a peptide. Ideally, I like to have patients use a combination of products with complementary benefits. There is no one product that's going to do it all."

Dr. Hirsch, a dermatologist who practices in Cambridge, Mass., noted that sales of cosmeceuticals were expected to reach $7.2 billion in 2008, up from $6.4 billion in 2004.

"Baby boomers are being seduced by marketing and antiaging claims of these products," she said. "The question is: Can these promises be fulfilled? Cosmeceuticals are not subject to the [Food and Drug Administration's] rigorous approval process. What kind of advice can we give to patients about how these products work and what they can really deliver?"

She discussed the benefits of the following cosmeceutical ingredients:

▸ Retinol (vitamin A). Found in many skin care creams, retinol is a relative of prescription tretinoin. "It's less irritating than tretinoin," Dr. Hirsch said. "It can increase epidermal water content and epidermal hyperplasia, but mainly it enhances collagen synthesis. That's one of the main ways it decreases the appearance of fine lines. It can also interfere with melanogenesis, which helps lighten sunspots."

▸ Niacinamide (vitamin B₃). This hydration repair agent increases ceramides and free fatty acids in the epidermis, and improves the lipid barrier. In turn, it decreases transepidermal water loss. "We recognize that preventing transepidermal water loss is important, not just for the health of the skin but also for photodamaged skin," she said. "If you can restore that barrier and prevent water loss, the skin will feel smoother and plumper."

▸ Coenzyme Q10 (ubiquinone). This fat-soluble antioxidant downregulates matrix metalloproteinases (MMPs). By inhibiting them, "you can help decrease the collagen breakdown in the skin," explained Dr. Hirsch, who is the immediate past president of the ASCDAS. "They are coenzymes for steps in the production of cellular energy, and they inhibit lipid peroxidation of plasma membranes and prevent oxidative stress."

▸ Idebenone. This substance is a potent synthetic derivative analogue of coenzyme Q10. "In initial studies, it was found to be a very powerful antioxidant, also downregulating MMP expression," improving roughness and dryness, and hydrating the skin, she said.

▸ Polyphenolic flavonoids. Derived from plants, these substances are antioxidant, anti-inflammatory, photoprotective, and anticarcinogenic. They are contained in wine, tea, coffee, and soy.

▸ Green tea. This ingredient contains the polyphenols epicatechin-3-gallate and epigallocatechin-3-gallate (EGCG). Studies have demonstrated that pretreatment of human skin with EGCG mitigates UVB-induced erythema.

▸ Coffeeberry. Derived from unripe coffee berries, this extract contains the polyphenolic antioxidants chlorogenic acid, quinic acid, and ferulic acid. In vitro, it has been found to upregulate collagen and connective tissue synthesis and downregulate collagen breakdown, Dr. Hirsch said.

▸ Peptides. Matrixyl, a procollagen pentapeptide fragment owned and licensed by Sederma SA, reportedly stimulates production of collagen I and II and fibronectin by fibroblasts.

Another product, acetyl hexapeptide-3 (Lipotec SA's Argireline), claims to mimic botulinum toxin-like effects in vitro. Overall, she was skeptical about topical products with injectablelike claims. "Better than Botox?" she asked. "No!"

Dr. Hirsch disclosed that she is the senior medical adviser for Vichy Laboratories, a division of L'Oreal USA.

LAS VEGAS — Dr. Alastair Carruthers remembers a time when the public perceived repeated injections of Botox as an experimental treatment reserved exclusively for the well-heeled crowd.

Today, the people most often requesting Botox treatment for dermatologic conditions are baby boomers who are accustomed to the concept of maintenance and are less concerned about vanity issues, compared with previous generations, he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

"They go to the gym regularly. They look after their diets. Having these same principles applied to their appearance is no great change for them," he said.

Baby boomers also are busy. "They don't have any down time," said Dr. Carruthers, who with his wife, Dr. Jean D.A. Carruthers, pioneered the cosmetic use of Botox.

"They're stressed, but they don't want to look it, and they have increased disposable income," he said.

Worldwide, Botox has 85% of the neurotoxin market while Dysport has much of the remainder, he said.

Despite its popularity and proven safety record over 2 decades of clinical studies, he finds so-called Botox parties a troubling development.

He described such parties as media events, pointing out that "you can't get proper consent because you don't have the individual in an informed consent situation. There's peer pressure, and [the drinking of] alcohol may be involved."

He showed a newspaper clipping of a Canadian dermatologist who applied the product at a Botox party without wearing latex gloves. "Need I say more?" commented Dr. Carruthers, who practices dermatology in Vancouver, B.C.

He went on to note that, while it's hard to imagine new uses for Botox, "I think we'll get better with it. I don't see expanding its cosmetic use. I think the lower face is still a challenge, even for expert injectors."

Dr. Carruthers does not anticipate a dermal filler on par with Botox being developed in the future, but he noted that "there is certainly going to be increasing competition. Will the product itself be changed? There may be changes to increase purity; they may reduce the human serum albumin that's in there, but I don't see changes to the actual molecule."

He added that short-acting toxins such as BTX-E and BTX-F may be of value postsurgically or after trauma.

"Wouldn't it be great," he asked, "to have a short-acting Botox [to use] when you throw your back out, or if you have spasms in your back and you can't move around? Or you've had surgery and you need to rest an area in the face or elsewhere?"

Dr. Carruthers disclosed that he is a consultant and performs research for Allergan Inc., Merz GmbH & Co., and Biform Medical Inc.

'Wouldn't it be great to have a short-acting Botox [to use] when you throw your back out?' DR. CARRUTHERS

LAS VEGAS — Dr. Alastair Carruthers remembers a time when the public perceived repeated injections of Botox as an experimental treatment reserved exclusively for the well-heeled crowd.

Today, the people most often requesting Botox treatment for dermatologic conditions are baby boomers who are accustomed to the concept of maintenance and are less concerned about vanity issues, compared with previous generations, he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

"They go to the gym regularly. They look after their diets. Having these same principles applied to their appearance is no great change for them," he said.

Baby boomers also are busy. "They don't have any down time," said Dr. Carruthers, who with his wife, Dr. Jean D.A. Carruthers, pioneered the cosmetic use of Botox.

"They're stressed, but they don't want to look it, and they have increased disposable income," he said.

Worldwide, Botox has 85% of the neurotoxin market while Dysport has much of the remainder, he said.

Despite its popularity and proven safety record over 2 decades of clinical studies, he finds so-called Botox parties a troubling development.

He described such parties as media events, pointing out that "you can't get proper consent because you don't have the individual in an informed consent situation. There's peer pressure, and [the drinking of] alcohol may be involved."

He showed a newspaper clipping of a Canadian dermatologist who applied the product at a Botox party without wearing latex gloves. "Need I say more?" commented Dr. Carruthers, who practices dermatology in Vancouver, B.C.

He went on to note that, while it's hard to imagine new uses for Botox, "I think we'll get better with it. I don't see expanding its cosmetic use. I think the lower face is still a challenge, even for expert injectors."

Dr. Carruthers does not anticipate a dermal filler on par with Botox being developed in the future, but he noted that "there is certainly going to be increasing competition. Will the product itself be changed? There may be changes to increase purity; they may reduce the human serum albumin that's in there, but I don't see changes to the actual molecule."

He added that short-acting toxins such as BTX-E and BTX-F may be of value postsurgically or after trauma.

"Wouldn't it be great," he asked, "to have a short-acting Botox [to use] when you throw your back out, or if you have spasms in your back and you can't move around? Or you've had surgery and you need to rest an area in the face or elsewhere?"

Dr. Carruthers disclosed that he is a consultant and performs research for Allergan Inc., Merz GmbH & Co., and Biform Medical Inc.

'Wouldn't it be great to have a short-acting Botox [to use] when you throw your back out?' DR. CARRUTHERS

LAS VEGAS — Dr. Alastair Carruthers remembers a time when the public perceived repeated injections of Botox as an experimental treatment reserved exclusively for the well-heeled crowd.

Today, the people most often requesting Botox treatment for dermatologic conditions are baby boomers who are accustomed to the concept of maintenance and are less concerned about vanity issues, compared with previous generations, he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

"They go to the gym regularly. They look after their diets. Having these same principles applied to their appearance is no great change for them," he said.

Baby boomers also are busy. "They don't have any down time," said Dr. Carruthers, who with his wife, Dr. Jean D.A. Carruthers, pioneered the cosmetic use of Botox.

"They're stressed, but they don't want to look it, and they have increased disposable income," he said.

Worldwide, Botox has 85% of the neurotoxin market while Dysport has much of the remainder, he said.

Despite its popularity and proven safety record over 2 decades of clinical studies, he finds so-called Botox parties a troubling development.

He described such parties as media events, pointing out that "you can't get proper consent because you don't have the individual in an informed consent situation. There's peer pressure, and [the drinking of] alcohol may be involved."

He showed a newspaper clipping of a Canadian dermatologist who applied the product at a Botox party without wearing latex gloves. "Need I say more?" commented Dr. Carruthers, who practices dermatology in Vancouver, B.C.

He went on to note that, while it's hard to imagine new uses for Botox, "I think we'll get better with it. I don't see expanding its cosmetic use. I think the lower face is still a challenge, even for expert injectors."

Dr. Carruthers does not anticipate a dermal filler on par with Botox being developed in the future, but he noted that "there is certainly going to be increasing competition. Will the product itself be changed? There may be changes to increase purity; they may reduce the human serum albumin that's in there, but I don't see changes to the actual molecule."

He added that short-acting toxins such as BTX-E and BTX-F may be of value postsurgically or after trauma.

"Wouldn't it be great," he asked, "to have a short-acting Botox [to use] when you throw your back out, or if you have spasms in your back and you can't move around? Or you've had surgery and you need to rest an area in the face or elsewhere?"

Dr. Carruthers disclosed that he is a consultant and performs research for Allergan Inc., Merz GmbH & Co., and Biform Medical Inc.

'Wouldn't it be great to have a short-acting Botox [to use] when you throw your back out?' DR. CARRUTHERS

LAS VEGAS — Although Botox has enjoyed a top-notch safety and efficacy record for nearly 2 decades, a mouse study published in the Journal of Neuroscience piqued the interest of Dr. Jean D.A. Carruthers, who, with her husband, Dr. Alastair Carruthers, pioneered the cosmetic use of botulinum toxin type A.

For the study, Italian investigators injected a research neurotoxin into the rat whiskers and found that it cleaved SNAP-25 (synaptosomal-associated protein, 25 kDa) in the seventh cranial nerve nucleus (J. Neurosci. 2008;28:3689–96).

In two other experiments, hippocampal injection of the neurotoxin crossed to the opposite hippocampus, whereas tectal injection led to cleaved SNAP-25 in the opposite retina.

"This is fascinating, because it's never been shown before that neurotoxin can migrate toward the brain or away from the brain," Dr. Carruthers said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "However, they were using enormous doses compared with our human dosing; it's like a fire hose compared to a drip. [There haven't been] any human data to support this."

She did, however, note some published studies that demonstrated that a glabellar injection of Botox improves mood and helps people cope with their depression and anxiety, "so maybe there is something happening there. Maybe this opens up a new area for research. But in 25 years of clinical use, there haven't been studies that show there are intracranial abnormalities. There is something going on here that requires different analysis and more study."

In 2005 Dr. Carruthers, a Vancouver-based ophthalmologist and oculoplastic surgeon, and her husband, a dermatologist and dermatologic surgeon, performed a long-term safety study of 50 subjects after a minimum of 5 years since their initial Botox treatment. "They'd had at least 10 treatment sessions; these weren't novices," she said.

The mean age of the patients was 42 years, and 92% were female.

Of 851 treatment sessions, there were three cases of brow ptosis in two subjects, one case of eyelid ptosis, and one case of dysphagia. "All of the side effects were mild and transient," said Dr. Carruthers, also of the department of ophthalmology at the University of British Columbia, Vancouver, where she specializes in facial cosmetic surgery. "None of the patients were particularly concerned about the adverse events because they all settled down."

A systematic review and meta-analysis of 36 studies of 2,309 subjects yielded similar results (J. Curr. Med. Res. Opin. 2004;20:981–90). Mild to moderate adverse events occurred in 25% of the Botox-treated group, compared with 15% for placebo. Focal weakness was the only adverse event with significantly higher incidence in the Botox-treated group. No serious adverse events were reported.

Transient, local complications "are what we want to continue seeing from the use of Botox," she said. "Immunogenicity is an overstated problem. Use only [Food and Drug Administration]-approved toxins, even for off-label indications."

She concluded that Botox is "a great drug that we should have great respect for. So when we see reports of serious adverse events, let's find out if it is Botox or if it's something else that's being used in a nonapproved way. Remember that there is nearly 20 years of Botox safety in worldwide publications."

Dr. Carruthers disclosed that she has relevant relationships with a number of pharmaceutical and medical device companies, including Allergan Inc. and Bioform Medical Inc.

LAS VEGAS — Although Botox has enjoyed a top-notch safety and efficacy record for nearly 2 decades, a mouse study published in the Journal of Neuroscience piqued the interest of Dr. Jean D.A. Carruthers, who, with her husband, Dr. Alastair Carruthers, pioneered the cosmetic use of botulinum toxin type A.

For the study, Italian investigators injected a research neurotoxin into the rat whiskers and found that it cleaved SNAP-25 (synaptosomal-associated protein, 25 kDa) in the seventh cranial nerve nucleus (J. Neurosci. 2008;28:3689–96).

In two other experiments, hippocampal injection of the neurotoxin crossed to the opposite hippocampus, whereas tectal injection led to cleaved SNAP-25 in the opposite retina.

"This is fascinating, because it's never been shown before that neurotoxin can migrate toward the brain or away from the brain," Dr. Carruthers said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "However, they were using enormous doses compared with our human dosing; it's like a fire hose compared to a drip. [There haven't been] any human data to support this."

She did, however, note some published studies that demonstrated that a glabellar injection of Botox improves mood and helps people cope with their depression and anxiety, "so maybe there is something happening there. Maybe this opens up a new area for research. But in 25 years of clinical use, there haven't been studies that show there are intracranial abnormalities. There is something going on here that requires different analysis and more study."

In 2005 Dr. Carruthers, a Vancouver-based ophthalmologist and oculoplastic surgeon, and her husband, a dermatologist and dermatologic surgeon, performed a long-term safety study of 50 subjects after a minimum of 5 years since their initial Botox treatment. "They'd had at least 10 treatment sessions; these weren't novices," she said.

The mean age of the patients was 42 years, and 92% were female.

Of 851 treatment sessions, there were three cases of brow ptosis in two subjects, one case of eyelid ptosis, and one case of dysphagia. "All of the side effects were mild and transient," said Dr. Carruthers, also of the department of ophthalmology at the University of British Columbia, Vancouver, where she specializes in facial cosmetic surgery. "None of the patients were particularly concerned about the adverse events because they all settled down."

A systematic review and meta-analysis of 36 studies of 2,309 subjects yielded similar results (J. Curr. Med. Res. Opin. 2004;20:981–90). Mild to moderate adverse events occurred in 25% of the Botox-treated group, compared with 15% for placebo. Focal weakness was the only adverse event with significantly higher incidence in the Botox-treated group. No serious adverse events were reported.

Transient, local complications "are what we want to continue seeing from the use of Botox," she said. "Immunogenicity is an overstated problem. Use only [Food and Drug Administration]-approved toxins, even for off-label indications."

She concluded that Botox is "a great drug that we should have great respect for. So when we see reports of serious adverse events, let's find out if it is Botox or if it's something else that's being used in a nonapproved way. Remember that there is nearly 20 years of Botox safety in worldwide publications."

Dr. Carruthers disclosed that she has relevant relationships with a number of pharmaceutical and medical device companies, including Allergan Inc. and Bioform Medical Inc.

LAS VEGAS — Although Botox has enjoyed a top-notch safety and efficacy record for nearly 2 decades, a mouse study published in the Journal of Neuroscience piqued the interest of Dr. Jean D.A. Carruthers, who, with her husband, Dr. Alastair Carruthers, pioneered the cosmetic use of botulinum toxin type A.

For the study, Italian investigators injected a research neurotoxin into the rat whiskers and found that it cleaved SNAP-25 (synaptosomal-associated protein, 25 kDa) in the seventh cranial nerve nucleus (J. Neurosci. 2008;28:3689–96).

In two other experiments, hippocampal injection of the neurotoxin crossed to the opposite hippocampus, whereas tectal injection led to cleaved SNAP-25 in the opposite retina.

"This is fascinating, because it's never been shown before that neurotoxin can migrate toward the brain or away from the brain," Dr. Carruthers said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "However, they were using enormous doses compared with our human dosing; it's like a fire hose compared to a drip. [There haven't been] any human data to support this."

She did, however, note some published studies that demonstrated that a glabellar injection of Botox improves mood and helps people cope with their depression and anxiety, "so maybe there is something happening there. Maybe this opens up a new area for research. But in 25 years of clinical use, there haven't been studies that show there are intracranial abnormalities. There is something going on here that requires different analysis and more study."

In 2005 Dr. Carruthers, a Vancouver-based ophthalmologist and oculoplastic surgeon, and her husband, a dermatologist and dermatologic surgeon, performed a long-term safety study of 50 subjects after a minimum of 5 years since their initial Botox treatment. "They'd had at least 10 treatment sessions; these weren't novices," she said.

The mean age of the patients was 42 years, and 92% were female.

Of 851 treatment sessions, there were three cases of brow ptosis in two subjects, one case of eyelid ptosis, and one case of dysphagia. "All of the side effects were mild and transient," said Dr. Carruthers, also of the department of ophthalmology at the University of British Columbia, Vancouver, where she specializes in facial cosmetic surgery. "None of the patients were particularly concerned about the adverse events because they all settled down."

A systematic review and meta-analysis of 36 studies of 2,309 subjects yielded similar results (J. Curr. Med. Res. Opin. 2004;20:981–90). Mild to moderate adverse events occurred in 25% of the Botox-treated group, compared with 15% for placebo. Focal weakness was the only adverse event with significantly higher incidence in the Botox-treated group. No serious adverse events were reported.

Transient, local complications "are what we want to continue seeing from the use of Botox," she said. "Immunogenicity is an overstated problem. Use only [Food and Drug Administration]-approved toxins, even for off-label indications."

She concluded that Botox is "a great drug that we should have great respect for. So when we see reports of serious adverse events, let's find out if it is Botox or if it's something else that's being used in a nonapproved way. Remember that there is nearly 20 years of Botox safety in worldwide publications."

Dr. Carruthers disclosed that she has relevant relationships with a number of pharmaceutical and medical device companies, including Allergan Inc. and Bioform Medical Inc.

PHOENIX — What's the most important aspect of filler technique for the lips?

Massage, Joseph Niamtu III, D.M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

"When you see someone who comes in from another office and they're unhappy and their lip is all lumpy, that's because there was no massage," said Dr. Niamtu, an oral and maxillofacial surgeon at Virginia Commonwealth University, Richmond.

"I keep a little dollop of Vaseline on the back of my glove that I use in massaging the lip," he explained. "I think it's so important to distribute that filler and make it nice and smooth; otherwise it can get pretty lumpy."

Dr. Niamtu presented a wide-ranging set of clinical pearls regarding facial filler injections. "Fillers are really exciting. They're so popular. And in this down economy, as the use of some procedures has gone down, the fillers and Botox [botulinum toxin type A] have gone up. I tell people if you can decorate a cake or caulk your bathtub, you can do fillers," he said.

Among the clinical pearls Dr. Niamtu discussed were how to effectively use miniblocks for optimal pain control, the value of a 0.9-mm fat-injecting cannula, and how to reverse an overaggressive correction:

▸ Control pain. "There's no doubt about it: If you make this a painless experience, you will overcome your competition," he said. As soon as his patients take a seat, a topical anesthetic is applied to the skin and mucosa, followed by ice to enhance the numbness, and then a series of small dental injections that Dr. Niamtu calls "miniblocks."

He said he dislikes conventional nerve blocks because they cause hours of drooling numbness. Instead, he administers a series of 0.2- or 0.3-cc injections of 2% Xylocaine (lidocaine HCl) with 1:100,000 epinephrine through a 32-gauge needle at four or five sites between the cuspids. These submucosal miniblocks are placed just above the sulcus of the upper lip and just below the sulcus of the lower lip. He also anesthetizes the nasolabial folds, injecting 0.2 cc of local anesthetic solution deep in a couple of places.

After a few minutes the perioral area is well anesthetized. Sensation returns within an hour after the procedure.

▸ Use a 0.9-mm fat-injecting canula. A remarkably atraumatic way to get filler into the lip, the fat-injecting canula glides easily through soft tissue.

"This has really changed my practice," Dr. Niamtu said. "You simply anesthetize the lip and make a puncture with an 18-gauge needle. The canula fits right on the filler syringe. You insert it and inject as you withdraw; I tell the patient we're putting air in the tire. Although it looks painful, it is much less traumatic than [multiple] needle sticks. This has really cut down on my postoperative swelling and bruising. I really like this when I'm doing volume."

▸ Get the right depth in lip injections. The target is the potential space between the mucosa and underlying muscle. "If you're in that potential space, you should have very low syringe pressure with very free flow antegrade and retrograde. If you are not in the correct space—in which case you're usually too superficial—you get blanching, increased syringe pressure, and you don't get the nice flow," he continued.

▸ Don't forget the philtrum. The philtrum and philtral columns are the most overlooked areas of the lip, in Dr. Niamtu's view. The philtral columns can be reconstructed with a conical injection from the alar base down to the vermilion border.

▸ Blunt the nasolabial folds. The most common mistake here is undertreatment. It takes two syringes of filler to get a good result in an adult.

"In this economy people don't want to buy two syringes, they want one syringe. I tell them, 'Save your money and come back,'" he said.

For injection of a fold or wrinkle with a hyaluronic acid filler, the improvement should happen right before the operator's eyes; otherwise the needle isn't in the right place.

"Now, if you're using silicone or Sculptra [poly-L-lactic acid], you will have some growth over time. But it's not going to get better tomorrow when you're using the hyaluronic acid fillers. If you don't see that improvement right away, you're probably too deep," he said.

▸ Reverse overcorrection. "Hyaluronidase is a savior. It's so nice to be able to tell patients you can reverse things they don't like," he explained.

Simply reconstitute the hyaluronidase with local anesthetic and inject it into the area of excess filler. It will dissolve hyaluronic acid filler in 24–48 hours and sometimes faster.

▸ Choose the right filler. Twenty years ago the choice was simple. Today there is a confusing array of fillers available, with yet more in the developmental pipeline.

"Now we're effectively bartenders," Dr. Niamtu observed. "Good injectors can do magic with just about anything."

Dr. Niamtu reported having no financial conflicts of interest regarding his presentation.

Using a 0.9-mm fat-injecting canula instead of a needle is less traumatic; the entire lip can be treated with a single puncture. COURTESY DR. JOSEPH NIAMTU III

'Itell people if you can decorate a cake or caulk your bathroom, you can do fillers.' DR. NIAMTU

PHOENIX — What's the most important aspect of filler technique for the lips?

Massage, Joseph Niamtu III, D.M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

"When you see someone who comes in from another office and they're unhappy and their lip is all lumpy, that's because there was no massage," said Dr. Niamtu, an oral and maxillofacial surgeon at Virginia Commonwealth University, Richmond.

"I keep a little dollop of Vaseline on the back of my glove that I use in massaging the lip," he explained. "I think it's so important to distribute that filler and make it nice and smooth; otherwise it can get pretty lumpy."

Dr. Niamtu presented a wide-ranging set of clinical pearls regarding facial filler injections. "Fillers are really exciting. They're so popular. And in this down economy, as the use of some procedures has gone down, the fillers and Botox [botulinum toxin type A] have gone up. I tell people if you can decorate a cake or caulk your bathtub, you can do fillers," he said.

Among the clinical pearls Dr. Niamtu discussed were how to effectively use miniblocks for optimal pain control, the value of a 0.9-mm fat-injecting cannula, and how to reverse an overaggressive correction:

▸ Control pain. "There's no doubt about it: If you make this a painless experience, you will overcome your competition," he said. As soon as his patients take a seat, a topical anesthetic is applied to the skin and mucosa, followed by ice to enhance the numbness, and then a series of small dental injections that Dr. Niamtu calls "miniblocks."

He said he dislikes conventional nerve blocks because they cause hours of drooling numbness. Instead, he administers a series of 0.2- or 0.3-cc injections of 2% Xylocaine (lidocaine HCl) with 1:100,000 epinephrine through a 32-gauge needle at four or five sites between the cuspids. These submucosal miniblocks are placed just above the sulcus of the upper lip and just below the sulcus of the lower lip. He also anesthetizes the nasolabial folds, injecting 0.2 cc of local anesthetic solution deep in a couple of places.

After a few minutes the perioral area is well anesthetized. Sensation returns within an hour after the procedure.

▸ Use a 0.9-mm fat-injecting canula. A remarkably atraumatic way to get filler into the lip, the fat-injecting canula glides easily through soft tissue.

"This has really changed my practice," Dr. Niamtu said. "You simply anesthetize the lip and make a puncture with an 18-gauge needle. The canula fits right on the filler syringe. You insert it and inject as you withdraw; I tell the patient we're putting air in the tire. Although it looks painful, it is much less traumatic than [multiple] needle sticks. This has really cut down on my postoperative swelling and bruising. I really like this when I'm doing volume."

▸ Get the right depth in lip injections. The target is the potential space between the mucosa and underlying muscle. "If you're in that potential space, you should have very low syringe pressure with very free flow antegrade and retrograde. If you are not in the correct space—in which case you're usually too superficial—you get blanching, increased syringe pressure, and you don't get the nice flow," he continued.

▸ Don't forget the philtrum. The philtrum and philtral columns are the most overlooked areas of the lip, in Dr. Niamtu's view. The philtral columns can be reconstructed with a conical injection from the alar base down to the vermilion border.

▸ Blunt the nasolabial folds. The most common mistake here is undertreatment. It takes two syringes of filler to get a good result in an adult.

"In this economy people don't want to buy two syringes, they want one syringe. I tell them, 'Save your money and come back,'" he said.

For injection of a fold or wrinkle with a hyaluronic acid filler, the improvement should happen right before the operator's eyes; otherwise the needle isn't in the right place.

"Now, if you're using silicone or Sculptra [poly-L-lactic acid], you will have some growth over time. But it's not going to get better tomorrow when you're using the hyaluronic acid fillers. If you don't see that improvement right away, you're probably too deep," he said.

▸ Reverse overcorrection. "Hyaluronidase is a savior. It's so nice to be able to tell patients you can reverse things they don't like," he explained.

Simply reconstitute the hyaluronidase with local anesthetic and inject it into the area of excess filler. It will dissolve hyaluronic acid filler in 24–48 hours and sometimes faster.

▸ Choose the right filler. Twenty years ago the choice was simple. Today there is a confusing array of fillers available, with yet more in the developmental pipeline.

"Now we're effectively bartenders," Dr. Niamtu observed. "Good injectors can do magic with just about anything."

Dr. Niamtu reported having no financial conflicts of interest regarding his presentation.

Using a 0.9-mm fat-injecting canula instead of a needle is less traumatic; the entire lip can be treated with a single puncture. COURTESY DR. JOSEPH NIAMTU III

'Itell people if you can decorate a cake or caulk your bathroom, you can do fillers.' DR. NIAMTU

PHOENIX — What's the most important aspect of filler technique for the lips?

Massage, Joseph Niamtu III, D.M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

"When you see someone who comes in from another office and they're unhappy and their lip is all lumpy, that's because there was no massage," said Dr. Niamtu, an oral and maxillofacial surgeon at Virginia Commonwealth University, Richmond.

"I keep a little dollop of Vaseline on the back of my glove that I use in massaging the lip," he explained. "I think it's so important to distribute that filler and make it nice and smooth; otherwise it can get pretty lumpy."

Dr. Niamtu presented a wide-ranging set of clinical pearls regarding facial filler injections. "Fillers are really exciting. They're so popular. And in this down economy, as the use of some procedures has gone down, the fillers and Botox [botulinum toxin type A] have gone up. I tell people if you can decorate a cake or caulk your bathtub, you can do fillers," he said.

Among the clinical pearls Dr. Niamtu discussed were how to effectively use miniblocks for optimal pain control, the value of a 0.9-mm fat-injecting cannula, and how to reverse an overaggressive correction:

▸ Control pain. "There's no doubt about it: If you make this a painless experience, you will overcome your competition," he said. As soon as his patients take a seat, a topical anesthetic is applied to the skin and mucosa, followed by ice to enhance the numbness, and then a series of small dental injections that Dr. Niamtu calls "miniblocks."

He said he dislikes conventional nerve blocks because they cause hours of drooling numbness. Instead, he administers a series of 0.2- or 0.3-cc injections of 2% Xylocaine (lidocaine HCl) with 1:100,000 epinephrine through a 32-gauge needle at four or five sites between the cuspids. These submucosal miniblocks are placed just above the sulcus of the upper lip and just below the sulcus of the lower lip. He also anesthetizes the nasolabial folds, injecting 0.2 cc of local anesthetic solution deep in a couple of places.

After a few minutes the perioral area is well anesthetized. Sensation returns within an hour after the procedure.

▸ Use a 0.9-mm fat-injecting canula. A remarkably atraumatic way to get filler into the lip, the fat-injecting canula glides easily through soft tissue.

"This has really changed my practice," Dr. Niamtu said. "You simply anesthetize the lip and make a puncture with an 18-gauge needle. The canula fits right on the filler syringe. You insert it and inject as you withdraw; I tell the patient we're putting air in the tire. Although it looks painful, it is much less traumatic than [multiple] needle sticks. This has really cut down on my postoperative swelling and bruising. I really like this when I'm doing volume."

▸ Get the right depth in lip injections. The target is the potential space between the mucosa and underlying muscle. "If you're in that potential space, you should have very low syringe pressure with very free flow antegrade and retrograde. If you are not in the correct space—in which case you're usually too superficial—you get blanching, increased syringe pressure, and you don't get the nice flow," he continued.

▸ Don't forget the philtrum. The philtrum and philtral columns are the most overlooked areas of the lip, in Dr. Niamtu's view. The philtral columns can be reconstructed with a conical injection from the alar base down to the vermilion border.

▸ Blunt the nasolabial folds. The most common mistake here is undertreatment. It takes two syringes of filler to get a good result in an adult.

"In this economy people don't want to buy two syringes, they want one syringe. I tell them, 'Save your money and come back,'" he said.

For injection of a fold or wrinkle with a hyaluronic acid filler, the improvement should happen right before the operator's eyes; otherwise the needle isn't in the right place.

"Now, if you're using silicone or Sculptra [poly-L-lactic acid], you will have some growth over time. But it's not going to get better tomorrow when you're using the hyaluronic acid fillers. If you don't see that improvement right away, you're probably too deep," he said.

▸ Reverse overcorrection. "Hyaluronidase is a savior. It's so nice to be able to tell patients you can reverse things they don't like," he explained.

Simply reconstitute the hyaluronidase with local anesthetic and inject it into the area of excess filler. It will dissolve hyaluronic acid filler in 24–48 hours and sometimes faster.

▸ Choose the right filler. Twenty years ago the choice was simple. Today there is a confusing array of fillers available, with yet more in the developmental pipeline.

"Now we're effectively bartenders," Dr. Niamtu observed. "Good injectors can do magic with just about anything."

Dr. Niamtu reported having no financial conflicts of interest regarding his presentation.

Using a 0.9-mm fat-injecting canula instead of a needle is less traumatic; the entire lip can be treated with a single puncture. COURTESY DR. JOSEPH NIAMTU III

'Itell people if you can decorate a cake or caulk your bathroom, you can do fillers.' DR. NIAMTU

LAS VEGAS — Dr. Gary D. Monheit's ideal cosmetic neurotoxin would have a rapid time of onset and a stable pharmacologic action throughout its time of activity.

Its effect would also be limited to the muscle sites of injection. "There are many variables that we put into this formula, such as the dilution we give it, the force of injection, and our injection points," he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "But we would like to have a toxin that stays stable where we're injecting it."

Other ideal properties include limited yet controlled diffusion or "the field of effect," few drug-related side effects such as pain or flulike symptoms, a natural-appearing response, and a prolonged action, "something greater than 6 months," he said.

At the present time no cosmetic neurotoxin meets all of these ideal properties, said Dr. Monheit of the departments of dermatology and ophthalmology at the University of Alabama at Birmingham. To date, Botox (Allergan Inc.) is the only cosmetic neurotoxin approved by the Food and Drug Administration, but Reloxin (known as Dysport in Europe and manufactured by Ipsen) is likely to enter the market this year.

It's difficult to directly compare Botox and Reloxin because the dosage units are registered differently (3:1 vs. 2.5:1, respectively), but Dr. Monheit maintained that the potency of the products "is essentially the same. The more units you put in of either, the more potent and the more the action is. But you have to look at each one of these [products] as a different drug. You can't truly convert back and forth because there is no direct scale to compare the units."

Because Botox is a heavier molecule than Reloxin (900 kd vs. 500–600 kd), some clinicians have presumed that Reloxin would tend to diffuse or migrate from the site of injection, leading to more adverse reactions than are seen with Botox. However, this presumption did not pan out in the phase III clinical studies of Reloxin.

"Diffusion is not relevant," commented Dr. Monheit, who was a clinical investigator for the Reloxin studies. "Spread or field of effect is dependent on dosage, dilution, and technical infection variables. Clinical data supports safety and efficacy at correct dosage and technique."

The phase III clinical trials of Reloxin demonstrated that the product's onset was in 2–3 days but occurred as soon as 24 hours for others. The average duration was 118 days.

Another neurotoxin in the pipeline is Xeomin, manufactured by Merz Pharmaceutical. One vial of the product contains botulinum neurotoxin type A free of complexing proteins, human serum albumin, and sucrose.

Xeomin is approved for use in Germany, and phase III clinical trials are currently underway in the United States. "Hearing Europeans who've used it, it seems very similar to Botox in its effect," said Dr. Monheit, who practices dermatology in Birmingham.

PurTox (Mentor Corp.) is also being investigated. This neurotoxin contains botulinum neurotoxin type A, yet it lacks the surrounding hemagglutinin protein complex. Phase II trials in the United States demonstrated that the end points of efficacy, safety, and longevity were similar to that seen with Botox for glabellar rhytides. "Its onset seems to be similar to Reloxin, while its activity is similar to Botox," Dr. Monheit said.

Phase III trials of PurTox in the United States began in July 2007.

Dr. Monheit reported that he is a consultant and clinical investigator for several pharmaceutical companies including Allergan, Ipsen, and Mentor Corp.

'There are many variables … but we would like to have a toxin that stays stable where we're injecting it.' DR. MONHEIT

LAS VEGAS — Dr. Gary D. Monheit's ideal cosmetic neurotoxin would have a rapid time of onset and a stable pharmacologic action throughout its time of activity.

Its effect would also be limited to the muscle sites of injection. "There are many variables that we put into this formula, such as the dilution we give it, the force of injection, and our injection points," he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "But we would like to have a toxin that stays stable where we're injecting it."

Other ideal properties include limited yet controlled diffusion or "the field of effect," few drug-related side effects such as pain or flulike symptoms, a natural-appearing response, and a prolonged action, "something greater than 6 months," he said.

At the present time no cosmetic neurotoxin meets all of these ideal properties, said Dr. Monheit of the departments of dermatology and ophthalmology at the University of Alabama at Birmingham. To date, Botox (Allergan Inc.) is the only cosmetic neurotoxin approved by the Food and Drug Administration, but Reloxin (known as Dysport in Europe and manufactured by Ipsen) is likely to enter the market this year.

It's difficult to directly compare Botox and Reloxin because the dosage units are registered differently (3:1 vs. 2.5:1, respectively), but Dr. Monheit maintained that the potency of the products "is essentially the same. The more units you put in of either, the more potent and the more the action is. But you have to look at each one of these [products] as a different drug. You can't truly convert back and forth because there is no direct scale to compare the units."

Because Botox is a heavier molecule than Reloxin (900 kd vs. 500–600 kd), some clinicians have presumed that Reloxin would tend to diffuse or migrate from the site of injection, leading to more adverse reactions than are seen with Botox. However, this presumption did not pan out in the phase III clinical studies of Reloxin.

"Diffusion is not relevant," commented Dr. Monheit, who was a clinical investigator for the Reloxin studies. "Spread or field of effect is dependent on dosage, dilution, and technical infection variables. Clinical data supports safety and efficacy at correct dosage and technique."

The phase III clinical trials of Reloxin demonstrated that the product's onset was in 2–3 days but occurred as soon as 24 hours for others. The average duration was 118 days.

Another neurotoxin in the pipeline is Xeomin, manufactured by Merz Pharmaceutical. One vial of the product contains botulinum neurotoxin type A free of complexing proteins, human serum albumin, and sucrose.

Xeomin is approved for use in Germany, and phase III clinical trials are currently underway in the United States. "Hearing Europeans who've used it, it seems very similar to Botox in its effect," said Dr. Monheit, who practices dermatology in Birmingham.

PurTox (Mentor Corp.) is also being investigated. This neurotoxin contains botulinum neurotoxin type A, yet it lacks the surrounding hemagglutinin protein complex. Phase II trials in the United States demonstrated that the end points of efficacy, safety, and longevity were similar to that seen with Botox for glabellar rhytides. "Its onset seems to be similar to Reloxin, while its activity is similar to Botox," Dr. Monheit said.

Phase III trials of PurTox in the United States began in July 2007.

Dr. Monheit reported that he is a consultant and clinical investigator for several pharmaceutical companies including Allergan, Ipsen, and Mentor Corp.

'There are many variables … but we would like to have a toxin that stays stable where we're injecting it.' DR. MONHEIT

LAS VEGAS — Dr. Gary D. Monheit's ideal cosmetic neurotoxin would have a rapid time of onset and a stable pharmacologic action throughout its time of activity.

Its effect would also be limited to the muscle sites of injection. "There are many variables that we put into this formula, such as the dilution we give it, the force of injection, and our injection points," he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "But we would like to have a toxin that stays stable where we're injecting it."

Other ideal properties include limited yet controlled diffusion or "the field of effect," few drug-related side effects such as pain or flulike symptoms, a natural-appearing response, and a prolonged action, "something greater than 6 months," he said.

At the present time no cosmetic neurotoxin meets all of these ideal properties, said Dr. Monheit of the departments of dermatology and ophthalmology at the University of Alabama at Birmingham. To date, Botox (Allergan Inc.) is the only cosmetic neurotoxin approved by the Food and Drug Administration, but Reloxin (known as Dysport in Europe and manufactured by Ipsen) is likely to enter the market this year.

It's difficult to directly compare Botox and Reloxin because the dosage units are registered differently (3:1 vs. 2.5:1, respectively), but Dr. Monheit maintained that the potency of the products "is essentially the same. The more units you put in of either, the more potent and the more the action is. But you have to look at each one of these [products] as a different drug. You can't truly convert back and forth because there is no direct scale to compare the units."

Because Botox is a heavier molecule than Reloxin (900 kd vs. 500–600 kd), some clinicians have presumed that Reloxin would tend to diffuse or migrate from the site of injection, leading to more adverse reactions than are seen with Botox. However, this presumption did not pan out in the phase III clinical studies of Reloxin.

"Diffusion is not relevant," commented Dr. Monheit, who was a clinical investigator for the Reloxin studies. "Spread or field of effect is dependent on dosage, dilution, and technical infection variables. Clinical data supports safety and efficacy at correct dosage and technique."

The phase III clinical trials of Reloxin demonstrated that the product's onset was in 2–3 days but occurred as soon as 24 hours for others. The average duration was 118 days.

Another neurotoxin in the pipeline is Xeomin, manufactured by Merz Pharmaceutical. One vial of the product contains botulinum neurotoxin type A free of complexing proteins, human serum albumin, and sucrose.

Xeomin is approved for use in Germany, and phase III clinical trials are currently underway in the United States. "Hearing Europeans who've used it, it seems very similar to Botox in its effect," said Dr. Monheit, who practices dermatology in Birmingham.

PurTox (Mentor Corp.) is also being investigated. This neurotoxin contains botulinum neurotoxin type A, yet it lacks the surrounding hemagglutinin protein complex. Phase II trials in the United States demonstrated that the end points of efficacy, safety, and longevity were similar to that seen with Botox for glabellar rhytides. "Its onset seems to be similar to Reloxin, while its activity is similar to Botox," Dr. Monheit said.

Phase III trials of PurTox in the United States began in July 2007.

Dr. Monheit reported that he is a consultant and clinical investigator for several pharmaceutical companies including Allergan, Ipsen, and Mentor Corp.

'There are many variables … but we would like to have a toxin that stays stable where we're injecting it.' DR. MONHEIT

LAS VEGAS — Before investing in a laser, take patient demographics into consideration, suggested Dr. Arielle N.B. Kauvar.

For example, for practices with a large number of patients with acne and rosacea, intense pulsed light (IPL) devices, pulsed dye lasers, or potassium-titanyl-phosphate (KTP) lasers would be good choices. "With all three of these, you can also treat pigmented lesions, so you'd have some versatility," Dr. Kauvar said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

IPL also can be used for hair removal, but for rosacea patients it may require more treatment sessions for individuals with discrete telangiectasia, said Dr. Kauvar, a dermatologist who practices in New York. Pulsed dye lasers also can be used to treat vascular birthmarks and hypertrophic scars.

For practices with a large number of patients asking for tattoo removal as well as rejuvenation, she recommends Q-switched lasers plus another device. "To effectively treat tattoos, you need three wavelengths," she said. "So you need to have one device that has all three wavelengths or you have to purchase two different lasers. Then you'll need a separate device for rejuvenation."

After a device has been selected, the new procedures will have to be accommodated into the work flow. If you currently have a busy medical dermatology practice, "you need to think about scheduling these patients at a different time," Dr. Kauvar said. "If you are already performing some type of cosmetic procedure such as injectables, liposuction, or sclerotherapy, you are at a distinct advantage because most patients seeking one cosmetic procedure will be interested in others as well."

She discussed other points to consider before purchasing a laser:

▸ Recognize patient needs. To determine what devices would be most appropriate, consider asking patients to fill out an office questionnaire to get a sense of treatments that interest them. Provide them with a list of common treatments "because they may not know that their problem is treatable," she noted. "Ask them to prioritize their list, and get some idea of what they would be willing to pay for a procedure or for a series of treatments."

When the day comes to add a new procedure, discount the initial treatments. This "allows you to develop experience with the procedure and it also provides you with feedback from your patients," she said.

▸ Set a monthly budget. Individual devices can cost up to $150,000. Most clinicians lease their equipment for 3–5 years, but month-to-month rental is another option. "You need to figure out how many procedures you have to perform to break even with each device that you add to your practice," Dr. Kauvar advised.

Renting a laser provides an opportunity to try it without a long-term commitment, but the rental costs are steep—usually $1,000/day per laser.

On the other hand, a 3-year lease on a $100,000 laser would cost about $3,000/month, while a 2-year lease on that same unit would cost about $2,000/month. "This monthly lease amount will vary to some degree depending on your termination options," she said. Leasing may provide a tax advantage in the form of depreciation of the equipment, but it also poses certain disadvantages, including a long-term financial commitment and the fact that technology evolves quickly.

Other costs to consider before buying a laser include maintenance contracts, which are "almost always advisable," said Dr. Kauvar, also of the department of dermatology at New York University. "Typically they come with 1- to 3-year warranties. But once the warranty expires, you will probably have to pay somewhere on the order of $5,000–$10,000/laser per year for a maintenance contract. You have to factor that into the cost of the device."

Maintenance contracts are important, "because these are fragile pieces of equipment, and they do break down."

Other hidden costs include items such as laser or device tips, replacement heads for IPL devices, cryogen, marketing materials in the form of brochures and advertisements, and possible installation of a dedicated high-voltage line. "You also need to assess your ventilation needs, because many of these lasers and devices generate a lot of heat output," she noted.

▸ Get training. Seek out appropriate training in laser safety and laser-tissue interactions, "not only didactic training sessions but hands-on laser training sessions for techniques and procedures," Dr. Kauvar said. "You have to absolutely understand what you're doing to the skin."

She also warned against delegating these procedures to untrained staff. "They're not cookbook procedures," she said. "When these lasers and devices are used inappropriately, they can lead to long-term dyspigmentation and scarring."

Dr. Kauvar disclosed having no relevant conflicts of interest.

LAS VEGAS — Before investing in a laser, take patient demographics into consideration, suggested Dr. Arielle N.B. Kauvar.

For example, for practices with a large number of patients with acne and rosacea, intense pulsed light (IPL) devices, pulsed dye lasers, or potassium-titanyl-phosphate (KTP) lasers would be good choices. "With all three of these, you can also treat pigmented lesions, so you'd have some versatility," Dr. Kauvar said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

IPL also can be used for hair removal, but for rosacea patients it may require more treatment sessions for individuals with discrete telangiectasia, said Dr. Kauvar, a dermatologist who practices in New York. Pulsed dye lasers also can be used to treat vascular birthmarks and hypertrophic scars.

For practices with a large number of patients asking for tattoo removal as well as rejuvenation, she recommends Q-switched lasers plus another device. "To effectively treat tattoos, you need three wavelengths," she said. "So you need to have one device that has all three wavelengths or you have to purchase two different lasers. Then you'll need a separate device for rejuvenation."

After a device has been selected, the new procedures will have to be accommodated into the work flow. If you currently have a busy medical dermatology practice, "you need to think about scheduling these patients at a different time," Dr. Kauvar said. "If you are already performing some type of cosmetic procedure such as injectables, liposuction, or sclerotherapy, you are at a distinct advantage because most patients seeking one cosmetic procedure will be interested in others as well."

She discussed other points to consider before purchasing a laser:

▸ Recognize patient needs. To determine what devices would be most appropriate, consider asking patients to fill out an office questionnaire to get a sense of treatments that interest them. Provide them with a list of common treatments "because they may not know that their problem is treatable," she noted. "Ask them to prioritize their list, and get some idea of what they would be willing to pay for a procedure or for a series of treatments."

When the day comes to add a new procedure, discount the initial treatments. This "allows you to develop experience with the procedure and it also provides you with feedback from your patients," she said.

▸ Set a monthly budget. Individual devices can cost up to $150,000. Most clinicians lease their equipment for 3–5 years, but month-to-month rental is another option. "You need to figure out how many procedures you have to perform to break even with each device that you add to your practice," Dr. Kauvar advised.

Renting a laser provides an opportunity to try it without a long-term commitment, but the rental costs are steep—usually $1,000/day per laser.

On the other hand, a 3-year lease on a $100,000 laser would cost about $3,000/month, while a 2-year lease on that same unit would cost about $2,000/month. "This monthly lease amount will vary to some degree depending on your termination options," she said. Leasing may provide a tax advantage in the form of depreciation of the equipment, but it also poses certain disadvantages, including a long-term financial commitment and the fact that technology evolves quickly.

Other costs to consider before buying a laser include maintenance contracts, which are "almost always advisable," said Dr. Kauvar, also of the department of dermatology at New York University. "Typically they come with 1- to 3-year warranties. But once the warranty expires, you will probably have to pay somewhere on the order of $5,000–$10,000/laser per year for a maintenance contract. You have to factor that into the cost of the device."

Maintenance contracts are important, "because these are fragile pieces of equipment, and they do break down."

Other hidden costs include items such as laser or device tips, replacement heads for IPL devices, cryogen, marketing materials in the form of brochures and advertisements, and possible installation of a dedicated high-voltage line. "You also need to assess your ventilation needs, because many of these lasers and devices generate a lot of heat output," she noted.

▸ Get training. Seek out appropriate training in laser safety and laser-tissue interactions, "not only didactic training sessions but hands-on laser training sessions for techniques and procedures," Dr. Kauvar said. "You have to absolutely understand what you're doing to the skin."

She also warned against delegating these procedures to untrained staff. "They're not cookbook procedures," she said. "When these lasers and devices are used inappropriately, they can lead to long-term dyspigmentation and scarring."

Dr. Kauvar disclosed having no relevant conflicts of interest.

LAS VEGAS — Before investing in a laser, take patient demographics into consideration, suggested Dr. Arielle N.B. Kauvar.

For example, for practices with a large number of patients with acne and rosacea, intense pulsed light (IPL) devices, pulsed dye lasers, or potassium-titanyl-phosphate (KTP) lasers would be good choices. "With all three of these, you can also treat pigmented lesions, so you'd have some versatility," Dr. Kauvar said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

IPL also can be used for hair removal, but for rosacea patients it may require more treatment sessions for individuals with discrete telangiectasia, said Dr. Kauvar, a dermatologist who practices in New York. Pulsed dye lasers also can be used to treat vascular birthmarks and hypertrophic scars.

For practices with a large number of patients asking for tattoo removal as well as rejuvenation, she recommends Q-switched lasers plus another device. "To effectively treat tattoos, you need three wavelengths," she said. "So you need to have one device that has all three wavelengths or you have to purchase two different lasers. Then you'll need a separate device for rejuvenation."

After a device has been selected, the new procedures will have to be accommodated into the work flow. If you currently have a busy medical dermatology practice, "you need to think about scheduling these patients at a different time," Dr. Kauvar said. "If you are already performing some type of cosmetic procedure such as injectables, liposuction, or sclerotherapy, you are at a distinct advantage because most patients seeking one cosmetic procedure will be interested in others as well."

She discussed other points to consider before purchasing a laser:

▸ Recognize patient needs. To determine what devices would be most appropriate, consider asking patients to fill out an office questionnaire to get a sense of treatments that interest them. Provide them with a list of common treatments "because they may not know that their problem is treatable," she noted. "Ask them to prioritize their list, and get some idea of what they would be willing to pay for a procedure or for a series of treatments."

When the day comes to add a new procedure, discount the initial treatments. This "allows you to develop experience with the procedure and it also provides you with feedback from your patients," she said.

▸ Set a monthly budget. Individual devices can cost up to $150,000. Most clinicians lease their equipment for 3–5 years, but month-to-month rental is another option. "You need to figure out how many procedures you have to perform to break even with each device that you add to your practice," Dr. Kauvar advised.

Renting a laser provides an opportunity to try it without a long-term commitment, but the rental costs are steep—usually $1,000/day per laser.

On the other hand, a 3-year lease on a $100,000 laser would cost about $3,000/month, while a 2-year lease on that same unit would cost about $2,000/month. "This monthly lease amount will vary to some degree depending on your termination options," she said. Leasing may provide a tax advantage in the form of depreciation of the equipment, but it also poses certain disadvantages, including a long-term financial commitment and the fact that technology evolves quickly.

Other costs to consider before buying a laser include maintenance contracts, which are "almost always advisable," said Dr. Kauvar, also of the department of dermatology at New York University. "Typically they come with 1- to 3-year warranties. But once the warranty expires, you will probably have to pay somewhere on the order of $5,000–$10,000/laser per year for a maintenance contract. You have to factor that into the cost of the device."

Maintenance contracts are important, "because these are fragile pieces of equipment, and they do break down."

Other hidden costs include items such as laser or device tips, replacement heads for IPL devices, cryogen, marketing materials in the form of brochures and advertisements, and possible installation of a dedicated high-voltage line. "You also need to assess your ventilation needs, because many of these lasers and devices generate a lot of heat output," she noted.

▸ Get training. Seek out appropriate training in laser safety and laser-tissue interactions, "not only didactic training sessions but hands-on laser training sessions for techniques and procedures," Dr. Kauvar said. "You have to absolutely understand what you're doing to the skin."

She also warned against delegating these procedures to untrained staff. "They're not cookbook procedures," she said. "When these lasers and devices are used inappropriately, they can lead to long-term dyspigmentation and scarring."

Dr. Kauvar disclosed having no relevant conflicts of interest.

PHOENIX — Nonablative fractional laser therapy applied at conservative settings achieved moderate global improvement in photodamaged hands in a pilot study.

Six months following their last treatment session, 8 of the 10 patients in the study showed a 26%-50% improvement in wrinkles, pigmentation, and skin texture, based on a formal investigator-rated scoring system, Dr. Neil S. Sadick reported at the annual meeting of the American Academy of Cosmetic Surgery. Patient assessments correlated well with the investigators' ratings.

"What you can expect is moderate, intermediate-level global improvement. But it's hard to achieve these global changes with any other type of technology," said Dr. Sadick, a dermatologist at Cornell University, New York, and immediate past president of the Cosmetic Surgery Foundation.

As is the case with other skin remodeling technologies, the results improved from 1 month post treatment to the 6-month follow-up mark, he noted.

The treatment sessions were well tolerated, side effects were mild and self-limited, and return to daily activities was immediate. "In our no-downtime world, this is what our patients are looking for in a nonsurgical venue," Dr. Sadick said.

The 10 patients (mean age, 57 years) were Fitzpatrick skin types I-III. Their bilateral photodamage on the dorsum of the hands was treated with a fractional 1,550-nm erbium-doped fiber laser, the first-generation Fraxel laser marketed by Reliant Technologies Inc.

Patients underwent five or six treatment sessions 3–4 weeks apart, with topical anesthesia. The laser energy setting was 6 mJ at the first session, increasing as tolerated by 2 mJ at each subsequent session. The total microthermal zone density was 1,000–2,000/cm

The technique used in treating the hands was the same as with Fraxel therapy on the face, with three or four passes per session being done, depending on the degree of photoaging.

All patients had immediate posttreatment erythema. Unlike on the face, where it resolves within a day or two, the erythema on the hands lasted for as long as 4 weeks.

"This is something that you need to tell your patients if you're going to use this modality," Dr. Sadick said.

Half of the patients developed mild edema. This was most prominent after the first treatment session, but it occasionally occurred after others as well.

No scarring or long-term inflammatory dyschromia occurred. Patients reported that the discomfort associated with treatment was mild but increased slightly with increasing laser energy.

Three patients underwent biopsies at baseline and again 3 and 6 months after their last session. Histologic evaluation using hematoxylin and eosin and elastin tissue stains showed a treatment-related decrease in atypical keratinocytes, increased rete ridge formation in the epidermis, enhanced collagen density in the epidermis and papillary and reticular dermis, improvement in the baseline irregular dermal architecture, and reduced solar elastosis. Consistent with clinical findings, there was no histologic evidence of scarring or inflammatory changes.

Dr. Sadick said he plans to study whether fractional laser therapy at greater energy densities will result in even better outcomes in fewer treatment sessions than in this initial study. "We're presently doing a study using a CO₂ Fraxel laser with just two treatment sessions. The results appear to be even better than in this pilot study," he said.

He disclosed that he performed his pilot study for Reliant in return for discounted equipment. He is on the speakers bureaus for laser and medical device manufacturers Cynosure, Palomar Medical Technologies Inc., Syneron Medical Ltd., and Cutera Inc.

The image at left shows a hand before treatment with a nonablative fractional laser at conservative settings. At right, the same hand is shown 6 months after the last of six treatment sessions. PHOTOS COURTESY DR. NEIL S. SADICK

PHOENIX — Nonablative fractional laser therapy applied at conservative settings achieved moderate global improvement in photodamaged hands in a pilot study.

Six months following their last treatment session, 8 of the 10 patients in the study showed a 26%-50% improvement in wrinkles, pigmentation, and skin texture, based on a formal investigator-rated scoring system, Dr. Neil S. Sadick reported at the annual meeting of the American Academy of Cosmetic Surgery. Patient assessments correlated well with the investigators' ratings.

"What you can expect is moderate, intermediate-level global improvement. But it's hard to achieve these global changes with any other type of technology," said Dr. Sadick, a dermatologist at Cornell University, New York, and immediate past president of the Cosmetic Surgery Foundation.

As is the case with other skin remodeling technologies, the results improved from 1 month post treatment to the 6-month follow-up mark, he noted.

The treatment sessions were well tolerated, side effects were mild and self-limited, and return to daily activities was immediate. "In our no-downtime world, this is what our patients are looking for in a nonsurgical venue," Dr. Sadick said.

The 10 patients (mean age, 57 years) were Fitzpatrick skin types I-III. Their bilateral photodamage on the dorsum of the hands was treated with a fractional 1,550-nm erbium-doped fiber laser, the first-generation Fraxel laser marketed by Reliant Technologies Inc.

Patients underwent five or six treatment sessions 3–4 weeks apart, with topical anesthesia. The laser energy setting was 6 mJ at the first session, increasing as tolerated by 2 mJ at each subsequent session. The total microthermal zone density was 1,000–2,000/cm

The technique used in treating the hands was the same as with Fraxel therapy on the face, with three or four passes per session being done, depending on the degree of photoaging.

All patients had immediate posttreatment erythema. Unlike on the face, where it resolves within a day or two, the erythema on the hands lasted for as long as 4 weeks.

"This is something that you need to tell your patients if you're going to use this modality," Dr. Sadick said.

Half of the patients developed mild edema. This was most prominent after the first treatment session, but it occasionally occurred after others as well.

No scarring or long-term inflammatory dyschromia occurred. Patients reported that the discomfort associated with treatment was mild but increased slightly with increasing laser energy.

Three patients underwent biopsies at baseline and again 3 and 6 months after their last session. Histologic evaluation using hematoxylin and eosin and elastin tissue stains showed a treatment-related decrease in atypical keratinocytes, increased rete ridge formation in the epidermis, enhanced collagen density in the epidermis and papillary and reticular dermis, improvement in the baseline irregular dermal architecture, and reduced solar elastosis. Consistent with clinical findings, there was no histologic evidence of scarring or inflammatory changes.

Dr. Sadick said he plans to study whether fractional laser therapy at greater energy densities will result in even better outcomes in fewer treatment sessions than in this initial study. "We're presently doing a study using a CO₂ Fraxel laser with just two treatment sessions. The results appear to be even better than in this pilot study," he said.

He disclosed that he performed his pilot study for Reliant in return for discounted equipment. He is on the speakers bureaus for laser and medical device manufacturers Cynosure, Palomar Medical Technologies Inc., Syneron Medical Ltd., and Cutera Inc.

The image at left shows a hand before treatment with a nonablative fractional laser at conservative settings. At right, the same hand is shown 6 months after the last of six treatment sessions. PHOTOS COURTESY DR. NEIL S. SADICK

PHOENIX — Nonablative fractional laser therapy applied at conservative settings achieved moderate global improvement in photodamaged hands in a pilot study.

Six months following their last treatment session, 8 of the 10 patients in the study showed a 26%-50% improvement in wrinkles, pigmentation, and skin texture, based on a formal investigator-rated scoring system, Dr. Neil S. Sadick reported at the annual meeting of the American Academy of Cosmetic Surgery. Patient assessments correlated well with the investigators' ratings.

"What you can expect is moderate, intermediate-level global improvement. But it's hard to achieve these global changes with any other type of technology," said Dr. Sadick, a dermatologist at Cornell University, New York, and immediate past president of the Cosmetic Surgery Foundation.

As is the case with other skin remodeling technologies, the results improved from 1 month post treatment to the 6-month follow-up mark, he noted.

The treatment sessions were well tolerated, side effects were mild and self-limited, and return to daily activities was immediate. "In our no-downtime world, this is what our patients are looking for in a nonsurgical venue," Dr. Sadick said.

The 10 patients (mean age, 57 years) were Fitzpatrick skin types I-III. Their bilateral photodamage on the dorsum of the hands was treated with a fractional 1,550-nm erbium-doped fiber laser, the first-generation Fraxel laser marketed by Reliant Technologies Inc.

Patients underwent five or six treatment sessions 3–4 weeks apart, with topical anesthesia. The laser energy setting was 6 mJ at the first session, increasing as tolerated by 2 mJ at each subsequent session. The total microthermal zone density was 1,000–2,000/cm

The technique used in treating the hands was the same as with Fraxel therapy on the face, with three or four passes per session being done, depending on the degree of photoaging.

All patients had immediate posttreatment erythema. Unlike on the face, where it resolves within a day or two, the erythema on the hands lasted for as long as 4 weeks.

"This is something that you need to tell your patients if you're going to use this modality," Dr. Sadick said.

Half of the patients developed mild edema. This was most prominent after the first treatment session, but it occasionally occurred after others as well.

No scarring or long-term inflammatory dyschromia occurred. Patients reported that the discomfort associated with treatment was mild but increased slightly with increasing laser energy.

Three patients underwent biopsies at baseline and again 3 and 6 months after their last session. Histologic evaluation using hematoxylin and eosin and elastin tissue stains showed a treatment-related decrease in atypical keratinocytes, increased rete ridge formation in the epidermis, enhanced collagen density in the epidermis and papillary and reticular dermis, improvement in the baseline irregular dermal architecture, and reduced solar elastosis. Consistent with clinical findings, there was no histologic evidence of scarring or inflammatory changes.

Dr. Sadick said he plans to study whether fractional laser therapy at greater energy densities will result in even better outcomes in fewer treatment sessions than in this initial study. "We're presently doing a study using a CO₂ Fraxel laser with just two treatment sessions. The results appear to be even better than in this pilot study," he said.

He disclosed that he performed his pilot study for Reliant in return for discounted equipment. He is on the speakers bureaus for laser and medical device manufacturers Cynosure, Palomar Medical Technologies Inc., Syneron Medical Ltd., and Cutera Inc.

The image at left shows a hand before treatment with a nonablative fractional laser at conservative settings. At right, the same hand is shown 6 months after the last of six treatment sessions. PHOTOS COURTESY DR. NEIL S. SADICK